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Yesterday, Today, Tomorrow – A letter to our patient, reflecting on our role as critical care physiotherapists during the COVID19 global pandemic

      The Yesterday Today and Tomorrow plant (Brunfelsia) is a tropical plant native to Brazil. Its lush green foliage is accented with unique blooms that change colour. The flowers bloom first as a purple or violet bloom. The next day that same bloom is pale lavender and the next day it is white.
      The Yesterday Today and Tomorrow plant symbolises our role as critical care physiotherapists, and represents the changed nature of this role working through the differing phases of the pandemic - before, now, and in the future.
      Before the pandemic, we used to be able to smile with you. You could easily see our facial expressions. We could laugh with you and talk to you – slowly building these important moments of connection and human interaction in the intensive care unit (ICU) to help engage you in rehabilitation. We would get to know your family and we learnt more about who you were outside of the ICU, before you became unwell. This information from your family helped us understand what level of physical condition, roles, and activities we could hope to return you to after your ICU stay. Before the pandemic, there were signs of life in the ICU – music coming from the bedside radio, families present, and photos of patients in the bed spaces as a reminder of life outside of the hospital.
      Uniquely, as critical care physiotherapists we see patients consecutively over many days – we get to see the colours change as patients recover, rehabilitate, and often return home to their communities. Sometimes this relationship can span weeks. It is rewarding work. Over time, much like the flowers of the Yesterday Today and Tomorrow plant, we get to see and be a part of your process of change and recovery.
      Now since the arrival of the pandemic everyone in the ICU, including the staff, are just trying to survive.
      Similar to many clinicians working in the ICU during the global pandemic, our experience of caring for patients like you has been altered significantly – it is now much harder to provide rehabilitation in the way we used to. We now wear masks so you can no longer easily see our faces which must make the ICU feel even lonelier at times. It is no longer as easy to speak with your family who are now frustrated, tired, and stressed by ongoing and more stringent visitor restrictions.
      These experiences of working in the pandemic have left us wondering if, in the future, we will be able to see the colours that change again.
      Yesterday you came into our ICU on maximal levels of oxygen, sedated, and on a breathing machine after you tested positive for COVID19. We met you in scrubs, gowns, masks, facemasks, hair caps, and gloves. We helped lead a team of people to help turn you onto your stomach to try and improve your breathing and oxygen levels. We continued this process for days, hoping that you would continue to get better. We helped the nurses turn, wash, and clean you. We helped the nurses with other tasks like processing your blood samples, to relieve pressure from them so they could continue their other vital duties that only they could do to keep you alive. You were so unstable requiring high amounts of medications to support your blood pressure. We were also providing this type of care for multiple other people on the same day. We moved from patient to patient, doing rounds to help move people, and we went home each day tired and sore, knowing that the next shift would be much of the same work.
      Today, after 20 days on a ventilator you woke up to an unfamiliar sea of strangers. A breathing tube down your throat. Not knowing what had happened to you, or what day it was, and no family at the bedside to comfort and support you. You wore your confusion like layers of clothing on a winter’s day, and slowly we began to help you discard those layers of confusion as we started to orientate you to who we were, and where you were. We began to encourage you to move your arms and legs, and we started to assist you to move in the bed. Your confusion soon became replaced by fear and anxiety, as you realised the enormity of your new disability and the uncertainty of your recovery ahead.
      But together, we all pushed on and we turned that fear and anxiety into purposeful, goal–driven activity with you. We were able to progress you to sit on the edge of the bed, an important first step in the long process of returning to standing and walking again. It took five people to do this - one person to manage the breathing tube, one person to ensure all your monitoring and medication lines moved freely, two people to support your body from the front, and one person to support you from behind, as you were too weak to hold yourself up without our physical support. You were still on high levels of oxygen and you could not breathe on your own. Yet you trusted us as strangers to help you, knowing this was probably the only pathway out of the ICU, alive.
      Today, you were able to sit in a chair. With your nurse, we helped turn your chair towards the window so that you could get a glimpse of the great big blue summer sky, and so you could feel the sunlight wrap around your skin again. You felt safe as we spoke reassuringly to you, encouraging you in your onwards progress – each step in your journey equally monumental and equally effortful. You were still critically unwell. We did this for a few days and eventually you got your breathing tube out. You were able to speak to us and we heard your voice for the first time. There, in between those monumental and effortful steps towards recovery, glimmers of hope began to emerge. We saw you every day for two weeks to help you stand and take steps across to a chair. You were unaware of the severity of your illness, still on some of the highest amounts of oxygen we have ever seen before.
      We got to know you. We knew you liked listening to the cricket and so after we finished your exercises with you, we would turn the radio on before leaving your bedspace – so you had some form of mental and cognitive stimulation to break up the endless days. We learnt you had a beloved dog called Ernie, waiting eagerly for your return home. Your family had been able to bring in some photos, which decorated your bedspace that taught us all who you were before your illness – although now you were almost unrecognisable from the photos due to the weeks in ICU that had left a mark on you. We talked about Ernie with you during your rehabilitation, and we looked at the photos of you and your family with you. We left the photos where you could ‘see’ your family, if not in person.
      Days later your condition changed. You started to deteriorate and you quickly became unwell again. The breathing tube was placed back in and you were returned to the ventilator. Progressively your other organs began to fail. We remembered again how fragile recovery was, and how fragile hope is.
      Today, you had a cardiac arrest. You needed a long period of resuscitation to try and get your heart beating again … but it was not possible. Your family could not be with you while you were dying as they could not travel in time to reach your bedside. The only people you had with you were the staff - people you did not know well, and could only recognise by their eyes.
      And then you were gone, and another fragment of our hope went with you.
      Tomorrow you will not be here. A new person will replace you in your bedspace. And we will begin the process again. But we will not forget you. Meanwhile we will keep hoping for the flowers to bloom again, and for the colours to begin to change like they used to – yesterday, today, and tomorrow.